Influence of delay on survival in patients with breast cancer: a systematic review

Socio-economic deprivation and stage of disease at presentation in women with breast cancer

BACKGROUND

This study describes and compares the pathological prognostic factors and surgeon assessment of stage of breast cancer of women living in affluent and deprived areas to assess whether clinical stage at presentation may explain the known poorer survival outcomes for deprived women.

PATIENTS AND METHODS

A population-based review of the case records of 417 women with breast cancer was carried out.

RESULTS

No difference in pathological criteria was found between the 88% of women living in affluent and deprived areas for whom such data were available. Clinical assessment of the remaining 50 cases showed that women living in deprived areas were more likely to present with locally advanced or metastatic disease.

CONCLUSION

The poorer survival of women from deprived areas with breast cancer may be explained by more deprived women presenting with advanced cancers.

Effect on survival of delays in referral of patients with breast-cancer symptoms: a retrospective analysis

BACKGROUND

From April 1, 1999, family physicians are required to refer all patients who have suspected breast cancer in the UK urgently to hospital, to be seen within 14 days of referral. We investigated whether delays by providers in routine practice for diagnosis influence survival.

METHODS

We did a retrospective analysis of 36,222 patients with breast cancer listed in the Yorkshire Cancer Registry. Data on delay after family-physician referral, hospital visit, and start of treatment were available, as well as on tumour grade and stage of presentation.

RESULTS

There was no evidence that provider delays of longer than 90 days adversely influenced survival. The time from family-physician referral to first hospital visit changed little (median 10 vs 13 days) from 1976 to 1995, whereas time from first visit to first treatment doubled (7 vs 13 days). More than 8% of patients younger than 50 years delayed longer than 90 days, compared with 3% of patients older than 50 years (p<0.001). 48% of younger patients had their first treatment within 30 days compared with 64% of those older than 50 (p<0.001). The survival for 5708 patients diagnosed in 1986-90 selected for survival analysis was 63% at 5 years, and 51% at 8 years. Patients who presented early and were treated in less than 30 days had significantly worse outcomes (p<0.001).

INTERPRETATION

Delays by providers in diagnosis of 3 months or more do not seem to be associated with decreased survival in patients presenting with breast cancer. The drive for all women with possible breast cancer to be seen within 14 days will divert resources from other services and is not supported by this study.

Factors predicting delayed presentation of symptomatic breast cancer: a systematic review

BACKGROUND

Delayed presentation of symptomatic breast cancer is associated with lower survival. Understanding of the factors that influence delay is important for the development of strategies to shorten delays. We did a systematic review to assess the quality and strength of evidence on risk factors for delays by patients and providers.

METHODS

We generated hypotheses about the relation between each putative risk factor and delay, against which we tested studies. We did searches to identify papers containing original data related to risk factors for delays by patients (n=86) and providers (n=28). We critically appraised the papers for inclusion in the review according to predefined criteria. The small number of studies of adequate quality did not allow formal meta-analysis. We therefore assigned strength of evidence according to a combination of the number and size of studies supporting, not supporting, or refuting the hypotheses.

FINDINGS

Most studies were deemed to be of poor quality and were excluded. Among 23 studies of adequate quality, however, there was strong evidence for an association between older age and delay by patients, and strong evidence that marital status was unrelated to delays by patients. Younger age and presentation with a breast symptom other than a lump were strong risk factors for delays by providers. Moderate evidence was shown for several other factors.

INTERPRETATION

The strength of the current evidence is inadequate to inform the development of specific strategies to shorten delays by patients or providers. Clarification of the findings of this review through a major programme of primary research is urgently required.

Fiberoptic endoscopic examination and biopsy in determining the extent of nasopharyngeal carcinoma

Introduction:

This paper reports on an ongoing primary care audit of cancer referrals undertaken in Scotland in 2006–2007 and 2007–2008.

Methods:

General practitioners (GPs) in Scotland were asked to review all new cancer diagnoses within their practice during the preceding year.

Results:

4181 patients were identified in year 1 and 12 294 in year 2. The pathway taken for patients to present to, and be referred from, their GP has been analysed for 7430 of the 12 294 patients identified within year 2 across five separate health boards. The time from first symptoms to presentation to a GP varied between tumour types, being the longest (median 30 days) for head and neck cancers and the shortest (median 2 days) for bladder cancer. In all, 25% of patients within the following tumour groups waited longer than 2 months to present to their GP following first symptoms: prostate, colorectal, melanoma and head and neck cancers. Once patients had presented to their GP, those with prostate and lung cancer were referred later (median time 11 days) than those with breast cancer (median time 2 days). The priority with which GPs referred patients varied considerably between tumour groups (breast cancer 77.5% ‘urgent’ compared with prostate cancer 44.7% ‘urgent’). In one health board the proportion of cancer patients being referred urgently increased from 46% to 58% between the first and second audit.

Conclusion:

Our data show that there are very different patterns of presentation and referral for patients with cancer, with some tumour groups being more likely to be associated with a delayed diagnosis than others.